{"id":33686,"date":"2026-07-06T16:31:02","date_gmt":"2026-07-06T16:31:02","guid":{"rendered":"https:\/\/healthcareethicscourses.com\/au\/?page_id=33686"},"modified":"2026-07-12T18:12:21","modified_gmt":"2026-07-12T18:12:21","slug":"clinical-documentation-record-keeping-for-chiropractors","status":"publish","type":"page","link":"https:\/\/healthcareethicscourses.com\/au\/clinical-documentation-record-keeping-for-chiropractors\/","title":{"rendered":"Clinical Documentation &#038; Record Keeping for Chiropractors"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"33686\" class=\"elementor elementor-33686\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b7abac8 e-con-full e-flex e-con e-parent\" data-id=\"b7abac8\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f289938 elementor-widget elementor-widget-html\" data-id=\"f289938\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<!-- Healthcare Ethics Courses \u2014 Chiropractic Board article \u2014 paste into an Elementor Custom HTML block. 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aria-hidden=\"true\">&rsaquo;<\/li>\r\n      <li><a href=\"\/au\/knowledge-support\/\">Chiropractic Board<\/a><\/li>\r\n      <li class=\"sep\" aria-hidden=\"true\">&rsaquo;<\/li>\r\n      <li aria-current=\"page\">Clinical Documentation and Record Keeping for Chiropractors<\/li>\r\n    <\/ol>\r\n  <\/nav>\r\n\r\n  <header class=\"head wrap\">\r\n    <h1>Clinical Documentation and Record Keeping for Chiropractors<\/h1>\r\n    <div class=\"meta\">\r\n      <span>8 min read<\/span>\r\n      <span class=\"dot\" aria-hidden=\"true\">&bull;<\/span>\r\n      <span>Last updated June 2026<\/span>\r\n    <\/div>\r\n    <p class=\"lead\">Good records underpin safe chiropractic care and protect you if your practice is questioned. This guide sets out what a good chiropractic record contains \u2014 including the reasoning, consent and imaging justification that matter most \u2014 and the privacy, retention and access rules to follow.<\/p>\r\n  <\/header>\r\n\r\n  <div class=\"takeaways wrap\">\r\n    <h2>Key takeaways<\/h2>\r\n    <ul>\r\n      <li>The shared <strong>Code of conduct<\/strong> requires accurate, up-to-date, factual, objective and legible records.<\/li>\r\n      <li>Record your <strong>clinical reasoning<\/strong> and the rationale for the care plan, not just the treatment given.<\/li>\r\n      <li>Document consent, material risks, and the justification for any <strong>imaging<\/strong>.<\/li>\r\n      <li>Make entries contemporaneously and never alter a record after a concern is raised.<\/li>\r\n      <li>Records are health information \u2014 store securely and retain per state and territory law.<\/li>\r\n    <\/ul>\r\n  <\/div>\r\n\r\n  <div class=\"wrap\">\r\n    <h2>Why documentation matters in chiropractic<\/h2>\r\n    <p>Clear records underpin safe chiropractic care and protect you if your practice is questioned. The shared <em>Code of conduct<\/em> requires accurate, up-to-date, factual, objective and legible records held securely. Given that consent, claims and the justification for care are recurring themes in chiropractic concerns, your record is where you demonstrate that your management was reasoned and consented.<\/p>\r\n\r\n    <h2>What a good chiropractic record contains<\/h2>\r\n    <ul>\r\n      <li>Presenting complaint, history, medications and red-flag screening.<\/li>\r\n      <li>Examination findings, including pertinent negatives, and the indications for any imaging.<\/li>\r\n      <li>Working diagnosis and clinical reasoning \u2014 and the rationale for the care plan.<\/li>\r\n      <li>Consent to assessment and treatment, and any material risks discussed.<\/li>\r\n      <li>Treatment provided, techniques used and the patient&#8217;s response.<\/li>\r\n      <li>Review plan, advice and any referral or safety-netting.<\/li>\r\n    <\/ul>\r\n    <aside class=\"note\"><p>Recording <em>why<\/em> a treatment or investigation was indicated is what demonstrates evidence-based, necessary care \u2014 directly answering the concerns that most often arise in chiropractic.<\/p><\/aside>\r\n\r\n    <h2>Imaging, necessity and consent<\/h2>\r\n    <p>Document the clinical justification for any imaging you order or recommend, and the consent discussion around it. Records that show a clear, evidence-based rationale for care are the best answer to any suggestion of unnecessary or indiscriminate treatment.<\/p>\r\n\r\n    <h2>Contemporaneous, unaltered, secure<\/h2>\r\n    <p>Make entries at or near the time of care and never alter a record once a concern arises \u2014 corrections should be transparent, dated and never obscure the original. Chiropractic records are health information and must be stored securely under the Australian Privacy Principles. Retention is set by state and territory law \u2014 generally at least seven years from the last entry for adults, and for children until a specified age \u2014 and patients have a right to access their records.<\/p>\r\n\r\n    <h2>Records and complaints<\/h2>\r\n    <p>If a concern arises, your records let you demonstrate reasoned, consented, necessary care. See our guides to <a href=\"\/au\/knowledge-support\/chiropractic-board\/advertising-compliance-chiropractors\/\">advertising compliance<\/a> and <a href=\"\/au\/knowledge-support\/chiropractic-board\/chiropractic-board-complaints-explained\/\">Chiropractic Board complaints<\/a>.<\/p>\r\n  <\/div>\r\n\r\n  <section class=\"courses wrap\">\r\n      <h2>Related CPD courses<\/h2>\r\n      <p class=\"intro\">Build the documentation habits this article describes with CPD for Australian practitioners:<\/p>\r\n        <a class=\"course\" href=\"https:\/\/healthcareethicscourses.com\/au\/courses\/documentation-for-healthcare-professionals\/\"><span class=\"course-tag\">CPD course<\/span><span class=\"course-name\">Documentation for Healthcare Professionals<\/span><span class=\"course-arr\"><svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/span><\/a>\r\n        <a class=\"course\" href=\"https:\/\/healthcareethicscourses.com\/au\/courses\/confidentiality-in-healthcare-practice-2\/\"><span class=\"course-tag\">CPD course<\/span><span class=\"course-name\">Confidentiality in Healthcare Practice<\/span><span class=\"course-arr\"><svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/span><\/a>\r\n        <a class=\"course\" href=\"https:\/\/healthcareethicscourses.com\/au\/courses\/professionalism-and-professional-standards-for-chiropractors\/\"><span class=\"course-tag\">CPD course<\/span><span class=\"course-name\">Professionalism and Professional Standards for Chiropractors<\/span><span class=\"course-arr\"><svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/span><\/a>\r\n  <\/section>\r\n\r\n  <section class=\"siblings wrap\">\r\n    <h2>Continue the Chiropractic Board series<\/h2>\r\n        <a class=\"sib\" href=\"https:\/\/healthcareethicscourses.com\/au\/chiropractic-board-complaints-explained\/\">Complaints Explained<svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/a>\r\n        <a class=\"sib\" href=\"https:\/\/healthcareethicscourses.com\/au\/professional-boundaries-in-chiropractic\/\">Advertising Compliance for Chiropractors<svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/a>\r\n  <\/section>\r\n\r\n  <section class=\"faq wrap\">\r\n    <h2>Frequently asked questions<\/h2>\r\n      <div class=\"faq-item\"><h3>What should a chiropractic record include?<\/h3><p>The presenting complaint and history, red-flag screening, examination findings including pertinent negatives, working diagnosis and reasoning, consent and material risks, treatment and response, and the review plan.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>Why record the rationale for care?<\/h3><p>Recording why a treatment or investigation was indicated demonstrates evidence-based, necessary care and answers concerns about unnecessary or indiscriminate treatment.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>Do I need to document imaging decisions?<\/h3><p>Yes. Record the clinical justification for any imaging and the consent discussion around it.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>How long must chiropractic records be kept?<\/h3><p>Retention is set by state and territory law \u2014 generally at least seven years from the last entry for adults, and for children until a specified age.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>Can I amend a record after a complaint?<\/h3><p>Only transparently \u2014 date the correction and never obscure the original. Altering notes undermines their credibility.<\/p><\/div>\r\n  <\/section>\r\n\r\n  <div class=\"wrap\">\r\n    <p class=\"disclaimer\">This article is general information for education and CPD purposes. It is not legal advice and does not create a practitioner\u2013adviser relationship. If you have received a notification, seek advice from your professional indemnity insurer, your union or professional association, or an independent lawyer experienced in health practitioner regulation. Healthcare Ethics Courses is an independent education provider and is not affiliated with, endorsed by, or acting on behalf of Ahpra or any National Board; regulator names are used for reference only.<\/p>\r\n  <\/div>\r\n\r\n  <script type=\"application\/ld+json\">\r\n{\r\n  \"@context\": \"https:\/\/schema.org\",\r\n  \"@graph\": [\r\n    {\r\n      \"@type\": \"Article\",\r\n      \"@id\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/chiropractic-board\/clinical-documentation-record-keeping-chiropractors\/#article\",\r\n      \"headline\": \"Clinical Documentation and Record Keeping for Chiropractors\",\r\n      \"description\": \"Clinical documentation and record keeping for chiropractors in Australia - clinical reasoning, consent, imaging justification, and privacy, retention and access rules.\",\r\n      \"inLanguage\": \"en-AU\",\r\n      \"datePublished\": \"2026-07-03\",\r\n      \"dateModified\": \"2026-07-03\",\r\n      \"author\": {\r\n        \"@type\": \"Person\",\r\n        \"name\": \"Dr Shehzad Iqbal\",\r\n        \"jobTitle\": \"Founder, Healthcare Ethics Courses\",\r\n        \"description\": \"MRCS, MRCGP, PG Cert Healthcare Law & Ethics (University of Dundee)\"\r\n      },\r\n      \"publisher\": {\r\n        \"@type\": \"Organization\",\r\n        \"name\": \"Healthcare Ethics Courses\",\r\n        \"url\": \"https:\/\/healthcareethicscourses.com\/\"\r\n      },\r\n      \"mainEntityOfPage\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/chiropractic-board\/clinical-documentation-record-keeping-chiropractors\/\",\r\n      \"about\": [\r\n        {\r\n          \"@type\": \"Thing\",\r\n          \"name\": \"Chiropractic Board of Australia\"\r\n        },\r\n        {\r\n          \"@type\": \"Thing\",\r\n          \"name\": \"Chiropractic regulation in Australia\"\r\n        }\r\n      ]\r\n    },\r\n    {\r\n      \"@type\": \"BreadcrumbList\",\r\n      \"itemListElement\": [\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 1,\r\n          \"name\": \"Home\",\r\n          \"item\": \"https:\/\/healthcareethicscourses.com\/au\/\"\r\n        },\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 2,\r\n          \"name\": \"Knowledge & Support\",\r\n          \"item\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/\"\r\n        },\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 3,\r\n          \"name\": \"Chiropractic Board\",\r\n          \"item\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/\"\r\n        },\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 4,\r\n          \"name\": \"Clinical Documentation and Record Keeping for Chiropractors\"\r\n        }\r\n      ]\r\n    },\r\n    {\r\n      \"@type\": \"FAQPage\",\r\n      \"mainEntity\": [\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"What should a chiropractic record include?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"The presenting complaint and history, red-flag screening, examination findings including pertinent negatives, working diagnosis and reasoning, consent and material risks, treatment and response, and the review plan.\"\r\n          }\r\n        },\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"Why record the rationale for care?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"Recording why a treatment or investigation was indicated demonstrates evidence-based, necessary care and answers concerns about unnecessary or indiscriminate treatment.\"\r\n          }\r\n        },\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"Do I need to document imaging decisions?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"Yes. 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